TWIN LAKES MEDICAL FOUNDATION INC

Provider Demographics

• NPI: 1205870862
• Name: TWIN LAKES MEDICAL FOUNDATION INC
• Entity type: Organization
• Organization Name: TWIN LAKES MEDICAL FOUNDATION INC
• Authorized Official - Title/Position: COO
• Authorized Official - First Name: DENEACE
• Authorized Official - Last Name: CLEMONS
• Authorized Official - Phone: 270-259-1626
• Mailing Address - Street 1: 908 WALLACE AVE
• Mailing Address - City: LEITCHFIELD
• Mailing Address - State: KY
• Mailing Address - Zip Code: 42754-1479
• Mailing Address - Country: US
• Mailing Address - Phone: 270-259-1626
• Mailing Address - Fax: 270-259-9582
• Practice Address - Street 1: 908 WALLACE AVE
• Practice Address - City: LEITCHFIELD
• Practice Address - State: KY
• Practice Address - Zip Code: 42754-1479
• Practice Address - Country: US
• Practice Address - Phone: 270-259-1626
• Practice Address - Fax: 270-259-9582
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-06-15
• Last Update Date: 2019-12-09

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Multi-Specialty
No	207V00000X	Allopathic & Osteopathic Physicians	Obstetrics & Gynecology		Group - Multi-Specialty
No	207X00000X	Allopathic & Osteopathic Physicians	Orthopaedic Surgery		Group - Multi-Specialty
No	207Y00000X	Allopathic & Osteopathic Physicians	Otolaryngology		Group - Multi-Specialty
No	207QS0010X	Allopathic & Osteopathic Physicians	Family Medicine	Sports Medicine	Group - Multi-Specialty
No	207R00000X	Allopathic & Osteopathic Physicians	Internal Medicine		Group - Multi-Specialty
No	208000000X	Allopathic & Osteopathic Physicians	Pediatrics		Group - Multi-Specialty
No	2084N0400X	Allopathic & Osteopathic Physicians	Psychiatry & Neurology	Neurology	Group - Multi-Specialty
No	208600000X	Allopathic & Osteopathic Physicians	Surgery		Group - Multi-Specialty
No	207Q00000X	Allopathic & Osteopathic Physicians	Family Medicine		Group - Multi-Specialty
No	208D00000X	Allopathic & Osteopathic Physicians	General Practice		Group - Multi-Specialty
No	231H00000X	Speech, Language and Hearing Service Providers	Audiologist		Group - Multi-Specialty
No	363LA2200X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Adult Health	Group - Multi-Specialty
No	363LF0000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Family	Group - Multi-Specialty
No	363LP2300X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Primary Care	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
KY	65923997	Medicaid
KY	65943045	Medicaid
KY	7100124530	Medicaid
KY	7100630070	Medicaid
KY	65937930	Medicaid
KY	7100072530	Medicaid
KY	65937047	Medicaid
KY	7100086880	Medicaid
KY	7100566530	Medicaid
KY	65939019	Medicaid
KY	70900162	Medicaid
KY	7100011670	Medicaid
KY	7100118990	Medicaid
KY	7100161750	Medicaid
KY	78903556	Medicaid
KY	78903556	Medicaid
KY	0667407	Other	PTAN
KY	0708203	Other	PTAN
KY	K007190	Other	PTAN
KY	K022340	Other	PTAN
KY	P400036689	Other	PTAN
KY	P400036706	Other	PTAN
KY	P400037009	Other	PTAN
KY	0301514	Other	PTAN
KY	0324704	Other	PTAN
KY	0708202	Other	PTAN
KY	K030021	Other	PTAN
KY	P400030972	Other	PTAN